Effect Modification by Social Determinants of Pharmacogenetic Medication Interactions on 90-Day Hospital Readmissions within an Integrated U.S. Healthcare System.

The present study builds on our prior work that demonstrated an association between pharmacogenetic interactions and 90-day readmission. In a substantially larger, more diverse study population of 19,999 adults tracked from 2010 through 2020 who underwent testing with a 13-gene pharmacogenetic panel, we included additional covariates to evaluate aggregate contribution of social determinants and medical comorbidity with the presence of identified gene-x-drug interactions to moderate 90-day hospital readmission (primary outcome). Univariate logistic regression analyses demonstrated that strongest associations with 90 day hospital readmissions were the number of medications prescribed within 30 days of a first hospital admission that had Clinical Pharmacogenomics Implementation Consortium (CPIC) guidance (CPIC medications) (5+ CPIC medications, odds ratio (OR) = 7.66, 95% confidence interval 5.45−10.77) (p < 0.0001), major comorbidities (5+ comorbidities, OR 3.36, 2.61−4.32) (p < 0.0001), age (65 + years, OR = 2.35, 1.77−3.12) (p < 0.0001), unemployment (OR = 2.19, 1.88−2.64) (p < 0.0001), Black/African-American race (OR 2.12, 1.47−3.07) (p < 0.0001), median household income (OR = 1.63, 1.03−2.58) (p = 0.035), male gender (OR = 1.47, 1.21−1.80) (p = 0.0001), and one or more gene-x-drug interaction (defined as a prescribed CPIC medication for a patient with a corresponding actionable pharmacogenetic variant) (OR = 1.41, 1.18−1.70). Health insurance was not associated with risk of 90-day readmission. Race, income, employment status, and gene-x-drug interactions were robust in a multivariable logistic regression model. The odds of 90-day readmission for patients with one or more identified gene-x-drug interactions after adjustment for these covariates was attenuated by 10% (OR = 1.31, 1.08−1.59) (p = 0.006). Although the interaction between race and gene-x-drug interactions was not statistically significant, White patients were more likely to have a gene-x-drug interaction (35.2%) than Black/African-American patients (25.9%) who were not readmitted (p < 0.0001). These results highlight the major contribution of social determinants and medical complexity to risk for hospital readmission, and that these determinants may modify the effect of gene-x-drug interactions on rehospitalization risk.

Impact of establishing a Geriatrics Workforce Enhancement Program clinic on preventive health and Medicare Annual Wellness Visits.

We established a Geriatrics Workforce Enhancement Program (GWEP) clinic to enhance resident training on comprehensive preventive care and chronic disease management, and to increase the number of older patients who received Medicare Annual Wellness Visit (AWV) preventive services. A total of 1,104 patients were tracked at baseline and during the intervention period. Patients were grouped into two categories: Adult (aged 55-64) and Senior (aged 65+). Clinical quality measures were monitored by electronic health record and tracked through monthly reports at baseline (May 2018) and during the intervention period (July 2018-June 2019). In the Senior group, the proportion of patients receiving the Medicare AWV increased after GWEP began (p <.001). Additionally, the Senior group showed significant improvements in the frequency of body mass index assessments (p = .04), colorectal cancer screenings (p < .001), advance directive documentation (p < .001), cognitive screenings (p < .001), and pneumococcal vaccinations (p < .001). In the Adult group, a trending increase was seen in influenza vaccinations (p = .06). Curricular innovations including the establishment of a GWEP clinic in our residency outpatient center, development of new educational materials, and use of a nurse coordinator resulted in significant improvements in the percentage of older adults who received the Medicare AWV benefit and preventive health performance metrics.

Tuberculosis: an overview.

Tuberculosis (TB) is still a public health issue; it continues to reign as one of the world's deadliest diseases. One-third of the world's population has been infected with TB. Identified cases of mycobacterium must be notified in an attempt to reduce the public health impact of TB on the population. TB transmission occurs via inhalation of droplet nuclei. The most common site for the development of TB is the lungs. Treatment of TB depends on whether latent TB or active TB is treated.

The effect of insurance-driven medication changes on patient care.

PURPOSE: Insurance plans periodically change their formularies to enhance medical efficacy and cost savings. Patients face challenges when formulary changes affect their treatment. This study assessed the impact of insurance-driven medication changes on primary care patients and examined implications for patient care. METHODS: We mailed questionnaires to a cross-sectional random sample of 1200 adult patients who had visited one of 3 family medicine practices within the past 6 months, asking them to describe problems they had encountered in filling medication prescriptions. We performed descriptive analyses of the frequency and distribution of demographic variables and conditions being treated. Using logistic regression analysis, we identified demographic and health-related variables independently associated with patient-reported problems caused by formulary changes. RESULTS: Three variables-a greater number of prescription medications taken, younger patient age, and reliance on government insurance-were independently associated with an increased likelihood of encountering a problem filling a medication. Patients who reported an insurance-related issue filling a new or existing prescription over the past year (23%) encountered an average of 3 distinct problems. Patients experienced adverse medical outcomes (41%), decreased satisfaction with the health care system (68%), and problems that burdened the physician practice (83%). Formulary changes involving cardiac/hypertension/lipid and neurologic/psychiatric medications caused the most problems. CONCLUSIONS: Insurance-driven medication changes adversely affect patient care and access to treatment, particularly for patients with government insurance. A better understanding of the negative impact of formulary changes on patient care and indirect health care expenditures should inform formulary change practices in order to minimize cost-shifting and maximize continuity of care.